| NW 88326

Assassination Records Review Board
Final Determination Notification

AGENCY : HSCA
RECORD NUMBER : 180-10068-10324
RECORD SERIES : STAFF PAYROLL RECORDS
AGENCY FILE NUMBER :

December 8, 1995
Status of Document: Postponed in Part

Number of releases of previously postponed information: 8 .

Reason for Board Action: The Review Board's decision was premised on several factors
including: (a) the significant historical interest in the document in question; (b) the
absence of evidence that the release of the information would cause harm to the United
States or to any individual.

Number of Postponements: 4

Postponements: All the postponements in this document represent Social Security numbers.

Reason for Board Action: The text is redacted because the public disclosure of the redaction could
reasonably be expected to constitute an unwarranted invasion of personal privacy, and that invasion of
privacy would be so substantial that it outweighs the public interest.

Substitute Language: SSN

Date of Next Review: 2017

Board Review Completed: 10/24/95

| Docld:32243290 Page 1

oe, ge Date:08/20/93
: Page:1
JFK ASSASSINATION SYSTEM

IDENTIFICATION FORM

AGENCY INFORMATION

, AGENCY : HSCA
RECORD NUMBER : 180-10068-10324

RECORDS SERIES :;:
STAFF PAYROLL RECORDS

- AGENCY FILE NUMBER :

ORIGINATOR :
FROM :
“TO 3

TITLE :

12/29/77
8

DATE
PAGES

SUBJECTS :;
_ HSCA, ADMINISTRATION
COLLINS, WENDY S.

DOCUMENT TYPE PRINTED FORM

CLASSIFICATION : U
RESTRICTIONS : 3
CURRENT STATUS : P
DATE OF LAST REVIEW : 07/07/93
OPENING CRITERIA :
COMMENTS :
Box #:1.
| . ([R] - ITEM IS RESTRICTED
| NW 88326

| Docld:32243290 Page 2

- LOUIS: STOKES, OHIO, CHAIRMAN

7 a ae eS

- RICHARDSON PREYER, N.C. _.. SAMUEL L. DEVINE, OHIO ae
L tWALTERE. FAUNTROY, D.C. - STEWART B, MC KINNEY, CONN, ° x o¥

“YVONNE BRATHWAITE BURKE, CALIF, CHARLES THONE, NESR. : : :

_ | CHRISTOPHER J. DODD, CONN, HAROLD S. SAWYER, MICH. | : . . : 7
.| {HAROLD E, FORD, TENN, _ . . 7 q ig ;
(0 ShReOYD ac FITHIAN, IND _. Select Committee on Assassinations —
\ SUROBERT: W. EDGAR, PA. : cet . mo .
(202) 225-4624 + U.S, House of Representatives
7 co ; a 3369 HOUSE OFFICE BUILDING, ANNEX 2

J ' WASHINGTON, D.C, 20515

- December 5, 1978

“The Honorable ‘Frank Thompson, Jr.
Chairman.

- Committee on’ House Administration
. ‘U. S. House of Representatives
| - - Washington, D. C. 20515
‘Dear Mr. Chairman:
. Effective December 1, 1978, the official duty station of Ms. Wendy

"collins has. been changed from Washington, D.C. to Pittsford, ‘Vermont.

“LS:th

“This change will remain in effect through the balance of the 95th Congress.


PAYROLL AUTHORIZATION FP°M

(Please Use Typewriter “>. wv - U.S. HOUSE OF REPRESENTATIVES“ (Any erasures, corrections, or changes. *.~:

Washington, D:C. 20515 on this form must be initialed by the

or Ballpoint Pen) — authorizing official.)

To the Clerk of the House of Representatives:

| hereby authorize the following payroll action:

Employee Name (First-Middle-Last) : Ty | Effective Date

Type of Action

O Appointment
0 Salary Adjustment
0 Title Change

Termination (At close of business on effective date)

CO Leave without pay (Beginning with effective date above and ending

close of business
. Specify Date

- (If type of action is an-Appointment, Salary Adjustment, or Title Change, complete ‘appropriate information below.)

Position Title

Gross Annual Salary *

wb

Dey i

* If employee is a civil service annuitant (includes U.S. House: of Representatives), the gross annual salary shown should include the annuity received by the employee -°

plus the salary received from the employing office.

(If Committee Employee, complete appropriate item below.)

1.0 — Stoning Committee: Staff—O Clerical or 1 Professional.

Mg, ny

2" Congress.

3. O Joint Committee.

(If Employee of an Officer of the House, complete item below.)

Position Number If applicable, Level

| certify that this: authorization is not in violation of 5 U.S.C. 3110(b), prohibiting the employment of:

relatives.
Dote__ 7) ae
(i appropriate, signature of Subcommittee Chairman or Ranking Minority Member) ~~ = "(Type or print name of Authorizing Official)
. GBA s PER
(Type or print name and title of above official) ~ eee Title vif Member, DistrictandSiote)SStCSCSC~CS ~

> All appointments and salary adjustments for employees under the: House Classification Act and for Committee em-
ployees; except those of the Committee on Appropriations; the Committee on the Budget,-and the Joint Committees, must ™
be approved by the Committee on House Administration.

APPROVED:

Chairman, Committee on House Administration

Office of Finance use only:

Office Code

Payroll_____ —---------------- _

(Revised: August | 1977)

On yas SORE Sta oe

“

se abbdie rt Cae,

Sead

A cecal Lee ate a thet

one ee

PAYROLL AUTHORIZATION FORM
‘(Please Use Typewriter .- . U.S. HOUSE OF REPRESENTATIVES . .. (Any.erasures, corrections, or changes:

_ authorizing official.)

To the Clerk of the House of Representatives:

| hereby authorize the following payroll action:

Employee Name (First-Middie-Last) ~~. ~~” Effective Date 8° |

fAppointment

{] Salary Adjustment

O1-Title Change

O1 Termination (Ai close of business on effective date}

Cl Leave without pay (Beginning with effective date above and ending

close of business

. Position Title

Re Soarea Abtarney

- * If employee is a: civil service annuitant (includes U.S. House of: Representatives), the gross annual salary shown should include the annuity réceived bythe employee” .

plus the salary received from the employing office.

(If Committee Employee, complete appropriate item below.)

1.0 Standing Committee: ‘Staff—O Clerical or 0 Professional.

Congress.
3. O Joint Committee.

(If Employee of an Officer of the House, complete item below.)

Position Number If applicable, Level_______.. Step______

I certify. that this authorization is not in violation. of 5 U.S.C. 3110(b), prohibiting the employment’ of.
relatives.

All appointments and salary. adjustments for employees under the-House Classification Act and for Committee em-"
: ployees, except: those of the Committee on Appropriations, the: Committee on the Budget, and: the Joint Committees, must
be approved by the Committee on House Administration.

APPROVED:

Chairman, Committee on House Administration

Office of Finance use only:

Office Code

or Ballpoint Pen) ~~ Washington, D.C. 20515 on this form must be initiated by the

Chenne e thle  e

ne nae Cena nO RAE aS OE

Taretebanr a2

tor labeBeccle at wan 4

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tafe ET ra

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“1976=599-393 2, iss

vans

New Carrier’s Control No.

FEDERAL BENETTS REG BENEFITS PROGRAM 22933 iW) ¢

(Read instructions on back of page 3.).

. _ : Old Carrier’s Control No.
_ TO EMPLOYING OFFICE: SHOW OLD CARRIER’S.CONTROL NUMBER ONLY IF ELECTION IS TO CANCEL .
ENROLLMENT OR TO CHANGE OPTIONS OR TYPE OF ENROLLMENT IN THE SAME PLAN.

1. NAME (LAST) - . (FIRST) . (MIOOLE INITIAL) 2. DATE OF BIRTH | 3. ARE YOU NOW

PART A a To ; S (Use numbers} _| | MARRIED?
Co lhws WI2nm D1 . . .
ALL WHO REGIS- 4. YOUR MAILING belo a. (NUMBER AND STREEF) LO : S % , Yes Cit]
TER MUST FILL a L. . , j
NtaspaRT. | 1630 | Helo A :
cerry) (STATE) (z1P CODE) ; 5. SOCIAL SECURITY ~ | 6.Sex
, ACCOUNT NUMBER . MALE CIb]

fo Waswmgien DC ey, 29 -ery-syo remelOt

IMPORTANT

: : : : $ ~. . :
“tTISTLLEGAL FOR AN EMPLOYEE OR A MEMBER OF HIS FAMILY TO BE COVERED UNDER MORE THAN ONE ENROLLMENT. 4F YOU ARE ALREADY COVERED THROUGH
~. | THE FAMILY ENROLLMENT OF ANOTHER FEDERAL OR DISTRICT OF COLUMBIA EMPLOYEE OR ANNUITANT YOU MUST REGISTER NOT TO ENROLL OR THE OTHER
- | ENROLLMENT MUST BE CANCELED OR CHANGED TO SELF ONLY. SIMILARLY, 1F A FAMILY MEMBER LISTED BY YOU IN PART B IS COVERED THROUGH HIS (OR. HER) OWN
ENROLLMENT, YOUCANNOT ELECT A FAMILY ENROLLMENT UNLESS THE FAMILY MEMBER CANCELS HIS (OR HER) ENROLLMENT. ALSO SEE BACK OF PAGES. 2 AND 3.

PART B 1.. telect to enroll ‘in a health benefits plan as shown below. | authorize deductions from my salary, compensation, or annuity to cover my _
share of the cost of the enrollment. - (Copy the information requested below from back page of brochure of the plan you select.)

FILL IN THIS | [Name oF ue ; —_ oT OPTION (HIGH OR LOW)
PART. IF YOU Blue C ass /f / Blue Slyeld S@euice Mert av /
: ca : H '

WISH TO ENROLL.

OR CHANGE

YOUR ENROLL: 2. In space below list all mi ban members without exception: . List your wife or husband first, then your unmarried children under age
a .« 22, including (a) legally adopted children and (b)- stepchildren; foster children, and illegitimate. children.who live with you in a regular
MENT IN A parent-child relationship. -Include also any unmarried child over 22 who became disabled before age 22 and who, because of the disability
“HEALTH BENE . is ‘incapable of self-support.. (Attach a doctor's certificate for a disabled child age 22 or over, if one is not already on file.) DO NOT LIS
one ‘ “> 7 “PARENTS OR OTHERS WHO ARE NOT ELIGIBLE FAMILY MEMBERS. THEY: WILL NOT RECEIVE BENEFITS, EVEN IF THEY
FITS PLAN. ‘ ARE DEPENDENT ON YOu AND.ARE LISTED.

¢ ae ‘ ES OF FAMILY ‘ME E s OATE OF BIRTH NAi F-FAMILY MEMBE RS DATE OF BIRTH
If enrollment is “de ‘ Nam Ss an A WLY: Me ® . 4 2 {Month, Day, Year) MES O AMIL (Month, Day, Year) ia

for Self Only,
answer. item 1. .
If enroliment.is.
. for Self and
Family, also an.

Wife or *
Husband

CHANGING YOUR
ENROLLMENT
ALSO FILL’ IN
PART D.

PART Cc . PLACE AN ‘’X'" IN ITEM 1 OR 2 WHICHEVER APPLIES:

. , 4, LELECT NOT TO ENROLL 'IN A PLAN UNDER THE FEDERAL - 2:: (ELECT TO CANCEL MY PRESENT. ENROLLMENT: UNDER THE.
FILL (IN.-THIS]| - EMPLOYEES HEALTH BENEFITS PROGRAM: nos - CODE NUMBER SHOWN BELOW

PART 1IF YOU . . : a . -
WISH NOT TO! ... ‘ a . : me Present Enrollment Code Number . an .
ENROLL OR-IF{: oe we . Ce : . : \f you elect to cancel |
YOU WISH TO]. ~~ - Te : be sure to read
; ,CANCEL YOUR so : : "Cancellation-of Enroilt-
, EN ROLLMENT.: coe _ an ; ‘ment’ on back of page 3.
’ PART D ANSWER. 1 TEMS 1; 2, AND 3 TO SHOW-ENROLULMENT CODE BEING CHANGED AND ELIGIBILITY FOR.CHANGE.
. ~ ons 1, ENROLLMENT CODE NUMBER’ 2 4 , | 2,, NUMBER OF EVENT WHICH PERMITS CHANGE, | 3. DATE OF EVENT WHICH PERMITS CHANGE.
CF LL . IN THIS 7 OF PRESENT-PLAN. toe - (See table on back of page 2 for proper number,)..
PART, AS WELL Se *

AS PART B, TO
CHANGE YOUR
REGISTRATION.

‘PART E Se i” . , ae oO WARNING.— Any intentional false statement:
; oo, ” . : oo 0 io a i = in this application or wilful misrepresentation
: er oe Ly Z yy a ro . relative thereto. is a violation of the Jaw
. TER MUST ELT A 7”, 5» * ; io yo A punishable by a fine of not more than $10,000 |
"IN THIS PART...-| -& ¢ W474, . i i : or imprisonment of not more than 5S years,
a aan (YOUR/SIGNATURE. DO NOT PRINT) : a * | or both. (18-U.S.C. 1001.) © pe
; ‘}4. NAME AND ADDRESS AINCLUDING ZIP CODE}OF EMPLOYING OFFICE... - + [2. DATE RECEIVEO IN © | 3. EFFECTIVE DATE OF
: a ; ” oo ; EMPLOYING OFFICE -|. ELECTION
PART F U.S. House of Representatives |
COMPLETED Office. of Finance : Washington, D. C. . 20515.. 4. PAYROLL OFFICE NO, |5. SF 2811 REPORT NO..
BY AGENCY | , , ,
: ee 00004832
| ASIGNATURE OF AUTHORIZED AGENCY OFFICIAL)” :
REMARKS | a
- FOR USE ONLY .
BY AGENCY. . . fo ; me . . .
‘NW 88326— —_ : Standard Form No. 2809

Docld:322433550 Page 6 _ Page 1 — To Payroll Office US Gi Sepplemene 890.1

munmkhar

Wie


|Poo  iteyp

%

ewriter is not available, bear down with ball-point pen to make legible copies:

HEALTH BENEFITS REGISTRATION FORM — _ | New Carrier's Contra! No.
FEDERAL EMPLOYEES HEALTH BENEFITS PROGRAM =
(Read instructions on back of page 3.) ” C

TO EMPLOYING OFFICE: SHOW OLD CARRIER'S CONTROL: NUMBER ONLY IF ELECTION 1S"TO CANCEL
ENROLLMENT OR TO CHANGE OPTIONS OR TYPE OF ENROLLMENT IN THE SAME PLAN,

3. ARE YOU NOW
MARRIED?

| 2, DATE-OF BIRTH
{Use numbers)

1, NAME (LAST) (FIRST) me, -  “(MIDOLE INITIAL)

S ,

“- PARTA |

4. YOUR MAILING ADDRESS. : (NUMBER AND STREE/T)

| ACL WHO REGIS.
TER MUST FILL So {) -
IN THIS PART. = in NM. —

T 5. SOCIAL-SECURITY,
COUNT NUMBER!

Yer S716"

. a Pen) s “IMPORTANT 0 ee wo
“IIS ILLEGAL FOR AN EMPLOYEE OR A MEMBER OF HIS FAMILY TO BE COVERED UNDER MORE THAN ONE ENROLLMENT. IF YOU'ARE ALREADY COVERED THROUGH - -
THE FAMILY. ENROLLMENT OF ANOTHER FEDERAL OR DISTRICT OF COLUMBIA EMPLOYEE OR ANNUITANT YOU MUST REGISTER NOT TO ENROLL OR THE OTHER
ENROLLMENT MUST 8E CANCELED OR: CHANGED TO SELF ONLY. SIMILARLY, !F A FAMILY MEMBER LISTED BY YOU IN PART B IS COVERED THROUGH HIS {OR HER) OWN: J.
ENROLLMENT; YOU CANNOT ELECT A FAMILY ENROLLMENT UNLESS THE .FAMILY MEMBER CANCELS HIS (OR HER} ENROLLMENT. ALSO SEE BACK OF PAGES.2 AND.3.; }

PART B -
FILL IN” THIS
| PART IF YOU
“}” WISH TO ENROLL
‘OR CHANGE
~.. YOUR ENROLL-
MENT. PNAS
> | HEALTH BENE-
] FITS PLAN. ..

‘ 1 1 elect to enrollina health benefits plan as shown below. | authorize deductions from my salary, compensation,’ or ‘annuity to cover-my
share of the cast of the enrollment. (Copy the information requested below from back page of brochure of.the plan you select.) .

[Bane oF Puan rn SGaROLLMENT COBENUMEER] |
Blue ross J Blue Sluield SCéwice 7 io /
enehR} Plan -_- ae YP oF tO wt,

_ 2. In space below list all eligible family members without exception: List your wife or husband first, then your unmarried children under age
_ 22, including ‘{a) legally adopted children and (b) ‘stepchildren, foster children, and ille itimate children who live with you in a regular’
. parent-child reldtionship.. Include also any unmarried child over 22 who became disabled before age 22'and who, because of the disabitity
“Is incapable of self-support. (Attach a doctor's certificate for a disabled child age 22 or over, if one is not already on file.) DO NOT List en
-PARENTS OR OTHERS WHO ARE NOT ELIGIBLE FAMILY MEMBERS. THEY WILL NOT RECEIVE:-BENEFITS, EVEN IF THEY, ode
ARE DEPENDENT ON YOU AND ARE LISTED. _ . anes ees De

DATE OF BIRTH

OPTION (HIGH OR LOW)

DATE-OF BIRTH °' .
(Month, Day, Year’

If enrolimentis -
for Self Only,”
answeritem 1.
-. H enrollment is
for. Self and
| Family, also an-
Vo sweritem:2. |.

_ “NAMES OF FAMILY MEMBERS ,

‘| Wife or
‘Husband

PIF YOUARE

-| CHANGING YOUR
“| ENROLLMENT.
‘+ ALSO “FILL. IND

; “ - PART C: . PLACE AN"X" _,
ALL AN THIS eee ee ee WRGeNercrs PROGRAM | a
“WISH NOT’ TO; : oo. ; : mo ae
-} ENROLLED OR SFP ae ; _ i : .If you elect to cancel
YOU WISH TOT. |... . . . . ; oo een oo be sure to read . Doo
“CANCEL: YOUR | - “Cancellation of Enroll-
ENROLLMENT: |: _ment’! on back of page 3. |

| PARTD
FILL -IN. THIS
PART, AS WELL |
AS PART.B, TO
CHANGE YOUR
REGISTRATION.

“; ELECT TO CANCEL MY PRESENT. ENR
CODE NUMBER SHOWN BELOW: — :

LIGIBILITY FOR.CHANGE.

> NUMBER OF EVENT WHICH PERMITS CHANGE.
(See tabla on back of page 2 for proper number.)

4: ENROLLMENT CODE N
"- OF, PRESENT PLAN

UMBER’ 3. DATE OF EVENT WHICH PERMITS CHANGE.

YEAR |

_WARNING.-— Any intentional false statement |

in this application or wilful misrepresentation
relative thereto is’ a violation of the law
punishable by a fine of not more than $10,000
or imprisonment ‘of not, more than 5 years,
or both (18 U.S.C, 1001.) -

3. EFFECTIVE DATE OF .
“ELECTION . ;

PARTE |
ALL WHO REGIS. .
“TER MUST FILL:
IN THIS PART.

(YOUR SIGNATURE. .DO NOT PRINT) 3 (DATE)

14. NAME ANO-ADDRESS {INCLUDING ZIP CODE) OF EMPLOYING OFFICE

2. DATE RECEIVEDIN
EMPLOYING OFFICE

|. | PARTF | -y.s, ouse-of Representatives — oo
|. TO UE LETED Jf. Office Or. Finance, Washington ,. DeGo, . 205215 . [a PAYROLL OFFICE NO. s
‘| BY AGENCY | re OO .

: — —— | - 90004832
(SIGNATURE OF AUTHORIZED.AGENCY OFFICIAL) — po Co

Tron useoney] 0 ee | 7 oes
Wi ~ 4D _ - . : . : Jo . , vo: : : “s ” an a 7 a ne oy : 7 : "ot a. = ; tole
WW 88226 - : “ — “" Standard Form No. 2809 °°
Boch: 3224839 (Page F-

. . Page 2 —_ To Insurance Carrier . : : . U.S. Civil Service Commission


HEALTH BENE ris SEeTPATIONSORE i .New — ofS
7 FEDERAL EMPLOYEES HEALTH BENEFIT! CoN. rouere) am
© (Read instructions .on back of page 3.) &) : l2 2 9 3 38 20)

. : _Old Carrier's Control No. ,
TO EMPLOYING OFFICE: SHOW OLD CARRIER’S CONTROL NUMBER ‘ONLY IF ELECTION is TO CANCEL Ot aor F
ENROLLMENT OR TO'CHANGE OPTIONS OR TYPE OF ENROLLMENT IN THE SAME PLAN. . . ; a

(inst Sa Garboce INTIAN 2 DATE OF BIRTH . [3 ARE YOU NOW.
_ co. se * (Use numbers) “MARRIED? ° : Co . os

. Oy . - SO \

ALLWHO REGIS- . : ) (NUMBER AND street)

: : wh 5 4 Cp é .

TER MUST FILL | jc.) Jvtulbsace th oP, Ad bap

LIN THIS PART: —_— ——— —_——— - -

IMPORTANT: : : :
Is ILLEGAL! FOR AN EMPLOYEE OR A MEMBER OF HiS FAMILY TO BE COVERED UNDER MORE THAN ONE ENROLLMENT. 1F ‘YOU ARE ALREADY COVERED THROUGH .
THE FAMILY ENROLLMENT OF ANOTHER FEDERAL OR DISTRICT OF COLUMBIA EMPLOYEE-OR ANNUITANT YOU MUST REGISTER NOT TO ENROLL OR’ THE OTHER

ENROLLMENT MUST BE CANCELED OR CHANGED TO SELF ONLY. SIMILARLY, 1F A FAMILY MEMBER LISTED BY YOU IN PART B IS COVERED THROUGH HIS [OR HER) OWN :
ENROLLMENT, YOUCANNOTELECT A FAMILY ENROLLMENT-UNLESS THE FAMILY MEMBER CANCELS HIS (OR HER) ENROLLMENT. ALSO SEE BACK OF PAGES 2 AND 3.

. PART B ‘ 1. Velect to enroll ina, health: ‘benefits plan as shown below. | authorize déductions from my salary, compensation; or annuity to cover my.
5 “
: . ‘ share of the cost of, the’ enrollment.

oa ae (Copy the information requested below ‘from back page of brochure of the plan you select.) - ;
FILL IN THIS: AME. OF PLAN Sn ; a Beye —_ OPTION (HIGH OR LOW) | | ENROLLMENT CODE. SNUMGER
‘PART. IF YOU ged. Eero ad © A Pa e ot, aed AEE yes el, bhp at pads 7 —— _
WISH:TO ENROLL a Cope yt AE ne Of] PREG

“OR CHANGE, : “* J

YOUR EN ROLL-.  2.01n space “below list all eligible family members without exception: List your wife or husband first, then your unmarried children under age .
7 - .22; including (a) Jegaily adopted children and (b) stepchildren, foster children, and- Megitimate children who live with you-in a regular:
MW ENT IN A _. | parent-child relationship. “Include also any Unmarried child. over 22 who became disabled

efore age. 22 and who, because of the gisabil ity. “
WEALTH. BENE- . . is incapable of.self-support. - (Attach a doctor’s certificate for a disabled child a Ss

{
; FeAE ns Z|. 7 a \
; \
\

le 22 or over, if one is not already on file.) DONOT LIST. .
PARENTS OR OTHERS WHO ARE NOT ELIGIBLE FAMILY MEMBERS. Tt EV. WILL NOT RECEIVE. “BEN FITS, EVEN: iF THEY.”
“| FITSPLAN. -ARE DEPENDENT ON YOU AND ARE LISTED. |
pe co . .. "DATE OF BIRTH a : ; “+ DATE OF BIRTH
it enrolment is Po NAMES OF FAMILY MEMBERS “| (Month, Oav:-¥ear) | NAMES OF FAMILY MEMBERS © 5"/. (Month, Day, Year!” ay
| for Self Only, —— — > een Os
~answer itém 1, ~' vite or re 0 qt tty . rr _ \
Hfenrolimentis, L . : ' : : | : a - * a ae : _ “| - : ; \
‘for ‘Self and |) |= Dr 7 Ce , ue oe ng re 2 | \
Family, also an- -] °°. : ae Poo, . woe, . oo re Set ! tres \
- sweritem 2... -——-— SS - -

IF YOU-ARE
‘CHANGING YOUR
ENROLEMENT
4) ALSO" FILL. -
PART D.”

“PART. Cc’ {PLACE AN ‘'X” IN ITEM 1 OR'2 WHICHEVER APPLIES:

1, VELECT.NOT TO-ENROLL IN A PLAN UNDER THE FEDERAL 2:
FELL IN. THs |! “EMPLOYEES HEALTH BENEFITS PROGRAM, .
~PART.-1F. YOU . .

+ WISH NOT TO]... Hienen Be
ENROLL. OR TE) . re ; _ a Co, ; . ie ; , ‘If you.elect to cancel
YOU. WISH TO 0 a ; ; _ : : .. | |-besure-to read:
‘CANCEL. YOUR rr ee -_ oe . P a : : Cancellation. of Enroll-'

ut . . ps . : ‘ment’ on back of page 3.

| ELECT TO ‘CANCEL MY. PRESENT ENROLLMENT UNDER THE
CODE NUMBER SHOWN BELOW:

ANSWER ITEMS 1, 2, AND 3° TO SHOW ENROLLMENT CODE BEING CHANGED AN D> ELIGIBILITY FOR CHANGE, .
Teneo: io. | 1. ENROLLMENT CODE NUMBER - 2. NUMBER OF EVENT WHICH PERMITS CHANGE. |3. DATE OF EVENT WHICH PERMITS CHANGE. |.
-FILL .IN THIS i “OF PRESENT PLAN : (See table on back of page 2 for proper number.)
PART,AS WELL] “oy a - ; per nu
_ | AS PART B,.TO.
REGISTRATION.

“PART E. “WARNING.—Any intentional false statement | -. - t

. . 7 : woo ; -- ‘ oo . in this application or wilful misrepresentation | ~ ..-

a a ee es whe ; “| relative thereto is a. violation of the law °
onc “ a A oe rs _ | punishable by a fine of not more than$10,000.| ~~: -
IN THIS PART : or ‘imprisonment of- not more than’ 5 “years,
ee Sor both: (18 U.S.C.-1007.).

. DATE RECEIVEDIN | '| 3. EFFECTIVE ‘DATE OF. al a . |
oo _ EMPLOYING OFFICE a . ELECTION | . . . .
PART F
COMPLETED - oe EEE 2. | & PAYROLL OFFICE NO. |S. SF 2811 REPORT NO, . -
‘BY AGENCY . oe . oo oo . : ,
REMARKS fo a a
- FOR USE ONLY : , 7 a ; . . .
BY AGENCY. ooo ee - | . .
lSwee o8326~ | ee aed Farm Nor SOOO
| Docld:33923250" Page 8 Page 3 — For Official Personne! Folder ; U.S. Civil Service Commission

FPM Supplement 890-1

“NW 88326 7 - oe

| if f typews iter is no 2 vailable, ‘bear down with ball-point. pen to make legible copies. :

EDERAL EMPLOYEES HEALTH BENEFITS PROGRAM

__ (Read instructions on back of page By ; ve - 22 3 3 3. 8 20 :

Old Carrier's Contro! No.
‘To. EMPLOYING OFFICE: SHOW OLD ‘CARRIER’S CONTROL.NUMBER ONLY IF ELECTION 1S TO CANCEL re Tos
ENROLLMENT OR-TO CHANGE OPTIONS OR. TYPE OF,ENROLLMENT IN THE SAME PLAN,

1.NAME. © (LASTD Dee (FIRST) .-

. (MIDDLE INITIAL) | 2. DATE OF BIRTH ~ 3. ARE. YOU NOW
oo - (Use numbers) © “MARRIED?

|, "ALL WHO REGIS.
TER MUST FILL.
IN THIS PART. -

“IMPORTANT |

Tis tCLLEGAL FOR AN EMPLOYEE OR A MEMBER OF HIS FAMILY TO: BE COVERED UNDER MORE THAN ONE ENROLLMENT. AF YOU ARE ALREADY COVERED THROUGH:
._ THEFAMILY ENROLLMENT OF ANOTHER FEDERAL OR. DISTRICT OF COLUMBIA EMPLOYEE OR ANNUITANT. ‘YOU MUST: REGISTER NOT TO ENROLL OR: THE OTHER®*

ENROLLMENT MUST BE CANCELED.OR CHANGED. TO SELF ONLY. SIMILARLY,1F. A FAMILY MEMBER LISTED BY YOU IN:PART B IS COVERED THROUGH HIS4{OR HER) OWN ~
L ENROLLMENT. “YOU CANNOT ELECT A FAMILY ENROLLMENT UNLESS THE FAMILY MEMBER CANCELS HIS (OR HER) ENROLLMENT. ALSO SEE BACK OF PAGES. 2. AND:3,
; | 1. lelect-to- énroll in a health benefits plan as shown below.
i PART BL ‘ ‘share of the cost. of the enrofiment.,
[FILL IN. THIS

NAME OF PLAN . - . ; oo, 2 OPTION (HIGH OR LOW) | [ ENROLLMENT CODE NUMBER]
PPaRT (F YOU} |; «0 fe APR eR ae LAD tae ceo ;

| WISH TO-ENROLL | | °°. pop ee

“ORSCHANGE

‘ ‘YOUR ENROLL- 2. In Space below. list ail eligible family members without-exception: List your wife or husband first, then your. unmarried chitdren ‘underage’.

, wh. - 22, including (a)- legaily ‘adopted ‘children and (b) ‘stepchildren, foster ‘children, and illegitimate ‘children. who live. with you in-a regular ~~

TMENT--UN A * parent-child relationship. ~Inctude also: any unmarried child over 22 who became disabled before age 22 and-who, because of the disability,
“HEALTH ‘BENE- _ is incapable.of. self-support: ‘

(Attach. a doctor's certificate for a disabled child age:22-or over, if one is not already on‘file.). DO.NOT LIS
-PARENTS OR. OTHERS.WHO ARE-NOT ELIGIBLE FAMILY MEMBERS. Tv EY.WILL NOT RECEIVE: ‘BEN FITS, EVEN: F THE?

“| authorize deductions from my salary, compensation,” ‘or annuity to cover my...
(Copy the information requested below from back page of brochure of the plan. you select. )

i

FITS PLAN... | ARE DEPENDENT ON YOU AND ARE LISTED

: ae | . DATE OF BIRTH a , . . ; - 70 J) paATE-oF BATH |
| ifenrotimentis “|. NAMES OF FAMILY, MEMGERS! (Month, Day: ¥ear) . NAMES OF FAMILY MEMBERS an hee intonth, Day, Year)
{> for Self Only, © [7 ; . — —_ : : :
= . answer item 1,
‘tfenroliment is -
for Self. and
| Family, also an-
ws -swer- item2;

[t1F YOUARE
CHANGING YOUR
ENROLLMENT
ALSO FILL IN’

: PLACE ANI X! IN ITEM 1 OR 2 WHICHEVER APPLIES:

PHIS |. EF M. Soap oss pee CODE NUMBER SHOWN BELOW:
“PART. Ne YOU}: ; : ; . ba a an me
[wish Nor TO] te ~ df ee ee mo}
“ENROLL ORUIFP Bete 7 TN a 7 Po - . | tf you. elect to cancel:
YOU: WISH TO oe eG . _ ae ‘ . be'sure to read. ot
U "Cancellation of Enroll-:
ment” of back of page 3:

ANSWER ITEMS 2, AND’3 TO SHOW ENROLLMENT.CODE ‘BEING CHANGED AND ELIGIBILITY FOR CHANGE. -

7 IN THIS: EN ROLUMENT CODE. NUMBER aa Fii $s ph 2. NUMBER OF EVENT WHICH PERMITS CHANGE. 3. (DATE: OF EVENT WHICH PERMITS CHANGE:
Lue OF PRESENT: PUAN = - epoe e (See table on back of.page 2 for. proper-‘number.)}. . a

PART, AS WELL.|:: - ; : .

AS PART: B, TO

CHANGE YOUR |"
‘REGISTRATION.

PART ES

' a ae ae : _ , fo ; in this application or wilful: misrepresentation |
| ALL WHO REGIS. (eg Ou 8 be |

; So . | relative thereto is a violation of - the’ law. bo.
_| TER Must FILL : _ ; 7 a A . 2 - ; ; 7 oa - | punishable by a fine of not.more than $10, 000 | ~

or. imprisonment of not more than 5. years,
or both (18 U.S.C: 1001.) |

}2. DATE:RECEIVED IN «=». | 3.* EFFECTIVE DATE. OF: :
' EMPLOYING OFFICE a oa ELECTION

“. PART F-

TO BE a 2 : 3 | =

> COMPLETED |. °° : ee “ee mon PAYROLL OFFICE NO. 15. SF 2811 REPORT NO.
BY AGENCY | J oo _ ne _ .

_ REMARKS”
"FOR. USE: ONLY |...
BY: AGENCY.

‘Standard Form No. 2809
2809-115-01 U.S. Civit Service Commission
FPM Supplement 890-1 ~
November 1972 -

-H : ALTH. BENEFITS REGISTRATION’ FORM - ; New Carrier's Control No.

_ WARNING.—Any intentional false statement pos

1d:32243290 Page 9 : on |


- +
ce eer nt et a eee eee

W 88326 oe
1d:32243290 Page 10 : rs ;

, Check the appr opriate pox te to the right:

PAYROLL INFORMATION FORM AND PERSONNEL AFFIDAVIT

PLEASE USE TYPEWRITER OR PRINT IN INK

CODE:
| Finance Office Use Oniy | U. S. HOUSE OF REPRESENTATIVES

U.S. House -
Employing Office Select toe — al
‘ BSS ASSET ORS | a

Social Security No. 2 2 <4 S/e G 3 Date of birth ___O go 2e2- S34

(Month —Day— Fe: ary .
a See ee es

_ ADDRESSES: a ee a
"Mailing address for p roll ch ( ik: home, fice, e

“ oe vee ng ac ress fo payroll pec (Boh oa e ice, jetc.):

i Soleute Capua ce a

wr a oe
ree a eae

Mailing: address for withholding tax ‘Statement

FINANCE OFFICE USE ONLY

Sntaprete ats tks Bank.Code: Eee RS a eae S “RT le Be ; «Ba: not.. cart ‘Bank. -Account .Number' unless check
i . J is # to ber mailed: to a ‘Bank)
wi? {4 ow tS ‘ i “ ae 1s ae
23 Bea L eS OO a oa moe toly ahh wa
PREVIOUS: FEDERAL CIVILIAN SERVICE |

{Ep House of RepresentativesOfice of 22

. maa ‘Separation date of last service @.

Ho yes co Ll gee Be
4 ‘Other Feder. al (Departments (including $ Senate and. Apéhitect)
vo * Agéney’ Mayr aA Gordes lyte aha eda re Se
( Name (if different £ fre om a present signature). _
‘While eniployed as dbove Iwas covered by: : TR ay Ik yar toe ce 8

Federal Employees’ Health Insurance: » pbivonas'e Ey not‘énvolled: fal eteladed. AOR: vee sic
Federal | Employees’ Life Insurance: = optional oO regular; waived; = excluded,

ELECTION OF RETIREMENT COVERAGE

; Covert age SRhder the provisions ‘of the Civil Serviée Retirement Aki ig ‘étended to einployées Of the House

of Representatives on a voluntary basis. Once you have. elected this coverage, and retirement deductions

hi have been, withheld, such, deductions. ‘cannot, be. discontinued SO: Jong as you: are. continuously, employed

nder t the. Act.

ene Je Sey pe
wy . ae er Cree

YES

I elect coverage under the: provisions of the: Civil Service Retirement Act and request. that: ‘deduc-_ 7 oe

tions begin at the earliest possible date. (If you have had previous Fedéral: or: Military, Service, ©

please submit dates, Agencies and Military Serial Number on a separate sheet. )s S No
I do not wish to elect coverage under the Retirement Act at thistime. = = - ee |

(Note: Legislative employees é are enot covered by the _— Security Act. 7

O ou. (Over) _ 7 wn! |

~


Distriet of Columbia oe a penne a a ee SS:

I do solemnly swear (or affirm) —_ oe
(1) That 1a Tama citizen of the United States.:.
£] if.in the service on the date.of enactment of the latest Genera] Government, Matters
; Appropriation Act, and being. eligible for citizenship, I had theretofore filed a declara-
‘t. . tion of intention to become a citizen ; ; 7 -
— “a I owe allegiance to the United States;
*{] Iam an alien.from Poland or the Baltic countries lawfully admitted to. thé United States
for permanent residence; ‘
(] Tama citizen of the Republic’ of the Philippines ;

Cd Iam a national of a country allied with the United States i in the current defense effort ;

x

~ (2) That my aiceptance and jiolding of office or employment with the U.S. House of Representatives
does not or (if this affidavit is executed by me prior to my acceptance of such office or employment) will
not constitute a violation of the first section of the A Act of August 9, 1955 > U.S.C. 7311), which reads as
follows: :

No person shall accept or hold office: or -eiriployment in 1 the. Government of. the United States or any agency: thereof,
_ including wholly owned Government corporations, who—
- (1) ‘advocates the overthrow of our constitutiorial form of government in the United States;
(2) is a member of an organization that advocates the overthrow of our constitutional form of government i in the
United States, knowing that such’ ‘organization so advocates;
(3) participates in any strike or asserts the right to strike against the Government of the United States or such
agency; or
(4) is a member of an organization of Government employees that asserts the right to strike against the Govern-
ment of the United States or such agencies, kriowing that such organization asserts such right; ; .

owe a ns ao Pats

(3) That I Oam receiving a pension, annuity, or retired. pay from. the United. States

RY am not
Government (if SO,. please; furnish source.and, claim number) ; Ro

. eos rn cote woe .

et ee i ine cen ae an ee A Salen in Ren EERRRRRRE PURER ERROR

(Name:and: loéation of administering agency) .

(Claim number)

A. That. this. Payroll Information Form and Personnel Affidavit is complete, true, and correct.

. “BY ‘That’ T will support and defena the Constitution: of the United States against alle enemies, foreign
und domestic; that I will bear true faith and allegiance to the same; that I take this obligation, freely,
without any mental reservation or purpose of evasion; and that I will well and | faithfully discharge the
duties of the office on which I am about to enter; So helpwieé-G ee : aan

om fea. ~
( U.S. GOVERNMENT PRINTING orrice 16—-82058-1 _


GS. House of Representatibes
. OFFICE OF THE CLERK

IMPORTANT NOTICE TO EMPLOYEE

Newly employed personnel must execute the attached combined PAYROLL INFORMATION FORM
and PERSONNEL AFFIDAVIT properly and submit them to the Office of Finance, where a Notary Public
is cn duty te perferm this service without charge. DO NOT SIGN PERSONNEL AFFIDAVIT UNTIL BEFORE
A NOTARY.

Currently employed personnel wishing to make changes in their records need only complete the perti-
nent section of the PAYROLL INFORMATION FORM, indicate their employing office, and affix their signa-
ture. Please be certain that information is legible enough for the Finance Office to identify the individual
making the change.

DETACH AND RETAIN THIS NOTICE

. Salary payments are made by check monthly and mailed to the address designated on the Payroll
Information Form. Checks are disbursed from the Office of Finance to normally reach the addressee on the
last working day of each month.

For additional information, contact the Office of Finance, 263 Cannon Office Building, Telephone
Extension 56515 or 57064.

EMPLOYEE BENEFITS

RETIREMENT: An employee of the House of Representatives is eligible to join the Federal Civil
Service Retirement System. Participation is voluntary, and action to elect retirement coverage may be
initiated at any time by completing the appropriate section of the Payroll Information Form. Once an

election is filed and the normal deduction of 74% percent of the gross salary commences, the.employee-
eannot discontinue deductions so long as he is continuously employed. (Note: Legislative employees.are .

not covered by the Social] Security Act.)

LIFE INSURANCE: An employee is automatically covered under the Federal Employees’ Group |
Life Insurance Act unless he waives or subsequently cancels such coverage by filing the required waiver .

form with the Office of Finance. The insurance coverage is $10,000; or an amount equal to the gross annual
salary, rounded to the next higher thousand dollars (if the salary is not a multiple of a thousand dollars),
plus an additional two thousand dollars ; whichever is the greater. Additional optional insurance coverage
in the amount of $10,000 is also available.

HEALTH BENEFITS: The Federal Employees’ Health Benefits Program is available on a voluntary
basis with costs partly financed by the Government. Within 31 days after the effective date of appointment,

' every employee must register to enroll in a plan or not to enroll. Future opportunities to enroll or tochange . ~
the type of enrollment are shown in the enclosed pamphlet. Also enclosed i is the necessary registration form, . -

Standard Form 2809.

_ US. SAVINGS BONDS: Monthly deductions for bonds in regular bond denominations may be
authorized. Authorization cards are available in the Finance Office.

WORK INJURY BENEFITS: An employee injured or incurring disease as a result of performance
of duty is entitled to medical care and monetary benefits under the provisions of the Federal Employees’
Compensation Act. In instances where such injury or disease is fatal, the employee’s family is entitled to
monetary benefits. The Compensation Act is administered by the Bureau of Employees’ Compensation,
U.S. Department of Labor. Forms for filing notices of injury and claims for compensation a are available
in the Office of Finance or from any Postmaster. ©

UNEMPLOYMENT COMPENSATION: An employee may under certain circumstances be entitled
to unemployment compensation if discharged or otherwise separated from his employment. The com-
pensation is usually payable by the State (including the District of Columbia) in which the employee had
his last service. However, a claim for benefits may be filed in the local office nearest the employee’s

residence. If an employee is discharged for misconduct, quits voluntarily without good cause, or refuses a.

suitable job without good cause, then there is a period of disqualification which varies from State to State.
The amount of payments and period of time payable also varies from State to State.

16—82058-1

W 88326 et re __.

Wi:37243290 Page 12


a“

MEMORANDUM

TO: Thomas Howarth, Budget Officer
Elizabeth Berning, Chief Clerk

FROM: I. Charles Mathews, Special Counsel
DATE: December 19, 1977

RE: Ms. Wendy Collins

Please be advised that Ms. Wendy Collins has
accepted the position of Senior Attorney Researcher with
the Select Committee on ASSasSsinations. Her effective
starting date will be December 29, 1977 and her
starting salary will be $18,000.00.
| Your full cooperation will be appreciated in

| familiarizing her with staff procedures and welcoming

her aboard.

: ICM: 31

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| Docid:32243290 Page 13 : re

|

W 88326

MEMORANDUM.

TO: ALL STAFF
RE: Payroll certification

‘The Regulations and Accountin Procedures for Allowances sand ae

Expenses of Committees,.Members and Employees of the U.S. House of

"Representatives require that, among other things, the Committee's
monthly payroll certification include the relationship, if any, of =~
each employee to any current Member of ‘Congress. This certification —

is signed monthly by our Chairman.

The foi lowing are the relationships to be included in the =
certification: . . .

father oe 2 nephew - ae _ ‘then anctaw

; first cousin re -

- Please ‘complete the appropriate portion below, sign and’ date
this form, which will then become a part of your permanent personnel .

file. If this status. changes, you must notify 1 the: Committee's Budget

_ Office immediately of the change. — | | 7 we
EFT am not related to any current (95th Congress) Member of F Congress.

| a I am related to a current (95th Congress) Member of Congress. i

(Please specify. )

Date

29 4 De?

mother ee ngece . - gister-in-Taw .
son oo ; - husband 5 si Stepfather - |

- daughter —. - . Wife ~ . . * gtepmother
brother = father-in-law =~ ~—s stepbrother

sister © - ,. mother-in-law ~ -- stepsister

uncle a os ' son-in-law =  ~.—---—sChal f-brother ne
aunt mo, a __, daughter-in-law oO half-sister Ss

i:37243290 Page 14

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